Travel Vaccinations

Please complete the following form 8 weeks prior to your travel arrangements and either hand this back at reception or email it to heathlane.surgery@nhs.net a member of the Nursing team will then contact you to arrange an appointment should you need advice or vaccinations.

Travel Risk Assessment

This field is hidden when viewing the form

Next Steps: Install the User Registration Add-On

This form requires the Gravity Forms User Registration Add-On. Important: Delete this tip before you publish the form.

Name

First Last

Date of birth

MM slash DD slash YYYY

Gender

Male

Female

Other

Telephone number

Email

Enter Email Confirm Email

Date of departure:

MM slash DD slash YYYY

Total length of trip:

Country 1.) Country to be visited

Country 1.) Exact location or region

Country 1.) City or rural

Country 1.) Length of stay

Country 2.) Country to be visited

Country 2.) Exact location or region

Country 2.) City or rural

Country 2.) Length of stay

Country 3.) Country to be visited

Country 3.) Exact location or region

Country 3.) City or rural

Country 3.) Length of stay

.

Have you taken out travel insurance for this trip?

Do you plan to travel abroad again in the future?

TYPE OF TRAVEL AND PURPOSE OF TRIP - PLEASE TICK ALL THAT APPLY

Holiday

Business trip

Expatriate

Volunteer work

Healthcare worker

Staying in hotel

Cruise ship trip

Safari

Pilgrimage

Medical tourism

Backpacking

Camping/hostels

Adventure

Diving

Visiting friends/family

Are you fit and well today(Required)

Yes

No

Any allergies including food, latex, medication(Required)

Yes

No

Severe reaction to a vaccine before(Required)

Yes

No

Tendency to faint with injections(Required)

Yes

No

Any surgical operations in the past, including e.g. your spleen or thymus gland removed(Required)

Yes

No

Recent chemotherapy/radiotherapy/organ transplant(Required)

Yes

No

Anaemia(Required)

Yes

No

Bleeding /clotting disorders (including history of DVT)(Required)

Yes

No

Heart disease (e.g. angina, high blood pressure)(Required)

Yes

No

Disability(Required)

Yes

No

Diabetes(Required)

Yes

No

Epilepsy/seizures(Required)

Yes

No

Gastrointestinal (stomach) complaints(Required)

Yes

No

Liver and or kidney problems(Required)

Yes

No

HIV/AIDS(Required)

Yes

No

Immune system condition(Required)

Yes

No

Mental health issues (including anxiety, depression)(Required)

Yes

No

Neurological (nervous system) illness(Required)

Yes

No

Respiratory (lung) disease(Required)

Yes

No

Rheumatology (joint) conditions(Required)

Yes

No

Spleen problems(Required)

Yes

No

Any other conditions?

Are you pregnant?

Yes

No

Are you breast feeding?

Yes

No

Are you planning pregnancy while away?

Yes

No

Have you undergone FGM / been cut / circumcised

Yes

No

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

PLEASE SUPPLY INFORMATION ON ANY VACCINES OR MALARIA TABLETS TAKEN IN THE PAST

Tetanus/polio/diphtheria

Typhoid

Cholera

Rabies

Yellow fever

MMR

Hepatitis A

Hepatitis B

 

Add Remove

part 2

Hepatitis B

Japanese encephalitis

BCG

Influenza

Pneumococcal

Meningitis

Tick borne encephalitis

Malaria Tablets

Other

 

Add Remove

Any additional information

Signature(Required)

Follow this link to access Privacy Policy

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Comments

This field is for validation purposes and should be left unchanged.

61908

Travel Vaccination Assessment Form

If your child has received a single dose of ‘Hepatitis A’ for holiday travel in the past, please book an appointment for a booster dose to give prolonged immunity (up to 10 years).

If you are travelling for more than one month, going to remote areas or visiting many destinations please book in for your holiday vaccination consultation as soon as possible, as you may need courses of vaccines that can take several months to deliver.

Please be aware that not all travel vaccines are available free of charge.  You will be advised by the nurse if a charge is applicable before vaccinations can be given.

Please note that some countries have a form of resistant malaria which requires medication that is only available on a private prescription or at specific health clinics.

A charge of £9.00 will be made for issue of a private prescription for malaria tablets, this would be in addition to the cost of the actual medication.

If you require any vaccinations relating to foreign travel you need to make an appointment with the practice nurse 8 weeks in advance. Please note last minute holidays do not constitute an emergency appointment on our behalf, however we will do our best to meet your requirements.

Information needed will include which countries and areas within countries that you are visiting to determine what vaccinations are required.

Some travel vaccines are ordered on a private prescription and these incur a charge over and above the normal prescription charge. This is because not all travel vaccinations are included in the services provided by the NHS.

We are no longer able to offer yellow fever vaccine, please visit Nathnac for more information for designated centres www.nathnac.org